Accumulative adverse childhood experiences (ACEs) have been shown to increase the risk of physical and mental health issues in children. More recently, accumulative positive childhood experiences (PCEs) have been shown to lessen the negative impact of ACEs; however, the research to date has rarely included children in foster care. We investigated the cumulative association between ACEs and PCEs among youth in foster care (N = 19,888) ages 5-18 in a midwestern state between 2011-2023 on the likelihood of mood challenges (MCs), including affective dysregulation, anger control, anxiety, and depression. We further stratified by age, biological sex, and race. ACEs were associated with a greater likelihood of MCs, while PCEs were associated with decreased likelihood of these outcomes. The effect of PCEs was greater for affect dysregulation and anger control compared to anxiety and depression. In the affect dysregulation and anger control model, PCEs have associations, as measured by beta coefficients, nearly three times and ten times those of ACEs, respectively. Whereas PCEs also have a higher association in depression and anxiety models, the differences are less pronounced, highlighting the potentially distinct role of positive experiences with others on children's emotion regulation.

Background:Strength development in children across a range of psychiatric diagnoses may reduce needs for mental health, social, and functioning support over time. A strength-based adjunct to child and adolescent mental health may foster the developmental context most helpful for achieving desired outcomes with positive developmental cascading effects. Methods:We longitudinally examined changes across 5 years in the Child and Adolescent Needs and Strengths Assessment in 2- to 18-year-old children (N = 30,103) from a public mental health system. Results:First, children who began with a greater number of strengths consistently had fewer support needs, not only at entry but also at one, two, three, four, and five years later. Second, initial strengths appeared to have cumulative positive cascades with reduced support needs over time; each additional strength a child possessed at the beginning of service was associated with a progressively faster decrease in their support needs each subsequent year. Furthermore, developing more strengths during the service period also predicted lower support needs one, two, three, four, and five years later. Finally, the impact of developing strengths over time varied depending on the child's age. Developing more strengths was linked to an increasingly rapid reduction in support needs each year for 2- to 5-year-olds. In contrast, developing more strengths was linked to a progressively slower reduction in support needs each year for 11- to 15-year-olds. Conclusion:We provide empirical support suggesting both the clinical utility of strength-based behavioral health care and the value of strength development in relation to reduction in support needs as a transdiagnostic clinical dimension. In turn, positive developmental cascading effects during a sensitive period early in development suggest the importance of early intervention. Strength-based mental health classification and treatment systems can be balanced with a traditional mental health symptom focus to more broadly leverage individuals' abilities for adaptation.

Background/Objectives: Sleep disturbance is common among youth in the child welfare system, yet the role of placement instability and placement setting in shaping sleep outcomes remains understudied. This study examined the association between placement instability, time spent in different care settings, and sleep disturbance among children in foster care. Methods: We conducted a retrospective cohort study using longitudinal administrative child welfare data from a Midwestern U.S. state, including 20,888 youth aged 5-18 years who entered foster care between 2010 and 2020. Sleep disturbance was assessed using the Child and Adolescent Needs and Strengths (CANS) sleep item. Baseline was defined as the first CANS assessment within one month of entry into care, and follow-up as the assessment closest to discharge or the end of a three-year observation window, whichever occurred first. We estimated association using a time-lagged linear mixed-effects model predicting sleep disturbance after each placement episode, including placement instability: 1 (reference), 2, 3, or ≥4 placement(s), time since placement, time spent in care settings (kinship, foster home, treatment foster home, congregate care, institutional care), and baseline trait factor scores derived from non-sleep CANS items, while controlling for sleep at the time of placement and demographics. Results: At baseline, 2016 children had actionable sleep disturbance (CANS sleep = 2 or 3; 1701 moderate and 315 severe). By the end of follow-up, this increased to 2884 children (2372 moderate and 512 severe). In linear mixed-effects models, placement instability demonstrated a dose-response association with higher subsequent sleep disturbance relative to one placement (2 placements: β = 0.025; 3 placements: β = 0.045; ≥4 placements: β = 0.067; all p ≤ 0.02). Time spent in kinship care was associated with lower sleep disturbance (β = -0.049; p < 0.001), whereas time spent in treatment foster homes was associated with higher sleep disturbance (β = 0.035; p < 0.001). Trauma in the family, medical/developmental needs, and internalizing/sexual issues were positively associated with sleep disturbance. Time and instability interactions showed modest attenuations of instability-associated sleep disturbance over time for higher placement counts. Conclusions: Placement instability is associated with progressively worse sleep disturbance over time among youth in foster care, even after controlling for sleep status at placement and baseline functioning. Sleep disturbance may represent an actionable indicator for the child welfare system, highlighting opportunities for targeted screening and support during placement transitions.

Accumulative adverse childhood experiences (ACEs) have been shown to increase the risk of physical and mental health issues in children. More recently, accumulative positive childhood experiences (PCEs) have been shown to lessen the negative impact of ACEs; however, the research to date has rarely included children in foster care. We investigated the cumulative association between ACEs and PCEs among youth in foster care (N=19,888) ages 5-18 in a midwestern state between 2011-2023 on the likelihood of mood challenges (MC), including anger control, anxiety, depression, and affective dysregulation. We further stratified by age, sex, and race. ACEs were associated with a greater likelihood of MCs, while PCEs were associated with decreased likelihood of these outcomes. The offset effect of PCEs was greater for affect dysregulation and anger control compared to anxiety and depression, highlighting the potentially distinct role of positive experiences with adults on children's emotion regulation. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study did not receive any funding. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The Ethics committee/IRB of the State of Idaho Department of Health and Welfare gave ethical approval for this work. The IRB of the University of Kentucky gave ethical approval for this work. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The source data are not available to the public due to patient information protection requirement.

Children and adolescents with serious emotional disturbance represent 7-12 percent of all youth in the United States. In 2017, the State of Idaho implemented the Youth Empowerment Service program, which allows youth with serious emotional disturbance who are younger than age eighteen living in households with income up to 300 percent of the federal poverty level to qualify for Medicaid and receive intensive, community-based treatment. A uniquely detailed method was used to assess the need for services: the Child and Adolescent Needs and Strengths tool, a ninety-seven-indicator instrument administered by a clinician. We used these indicators and Idaho's 2018-22 administrative Medicaid claims data to study the association between children and adolescents' clinical needs complexity and their actual Medicaid behavioral and mental health service use. Our findings show that there was a substantial proportion of youth who were underusing Medicaid behavioral and mental health care services, and there were virtually no overusers. Our findings have implications for the appropriateness of Medicaid utilization management in behavioral health care and program efforts to maintain families with youth having serious emotional disturbance in the Youth Empowerment Service program.

Background: Among children enrolled in behavioral health treatment, those with multiple trauma experiences (known as Adverse Childhood Experiences, or ACEs) typically see worse outcomes. In this study, we examine whether having or building strengths can help such children become more resilient and experience better outcomes. Objective: We examined the relationship between children's traumatic experiences, strengths, and clinical improvement, testing whether building strengths can help reduce the negative impact of ACEs on children's response to treatment. Participants and Setting: We used data from an evidence-based assessment to understand the clinical and functional needs and strengths of 5,423 children (ages 6-20) receiving treatment between 2019 and 2022 within a large community agency located in California. Methods: To classify children by both level and rate of improvement, we relied on machine learning and principal components analysis. To determine the relationships between ACEs, strengths, and improvement, we used a variety of predictive models and descriptive analyses. Results: After classifying children as being either "Faster", "Slower", or "Minimal" improvers, our analyses revealed that while higher total ACEs increases the likelihood of being a Slower improver, this effect can be mitigated by building strengths. Conclusions: These results suggest that children with more ACEs are likely to require a longer duration of treatment before improvement is seen. They also suggest that promoting resilience--specifically focusing on building strengths--may lead to more efficient and effective care, particularly for children with significant trauma histories.

Background Complex social determinants of health may not be easily recognized by health care providers and pose a unique challenge in the vulnerable pediatric population where patients may not be able to advocate for themselves. The goal of this study was to examine the acceptability and feasibility of health care providers using an integrated brief pediatric screening tool in primary care and hospital settings. Methods The framework of the Child and Adolescent Needs and Strengths (CANS) and Pediatric Intermed tools was used to inform the selection of items for the 9-item Child and Adolescent Needs and Strengths-Pediatric Complexity Indicator (CANS-PCI). The tool consisted of three domains: biological, psychological, and social. Semi-structured interviews were conducted with health care providers in pediatric medical facilities in Ottawa, Canada. A low inference and iterative thematic synthesis approach was used to analyze the qualitative interview data specific to acceptability and feasibility. Results Thirteen health care providers participated in interviews. Six overarching themes were identified: acceptability, logistics, feasibility, pros/cons, risk, and privacy. Overall, participants agreed that a routine, trained provider-led pediatric tool for the screening of social determinants of health is important (n = 10, 76.9%), acceptable (n = 11; 84.6%), and feasible (n = 7, 53.8%). Interpretation Though the importance of social determinants of health are widely recognized, there are limited systematic methods of assessing, describing, and communicating amongst health care providers about the biomedical and psychosocial complexities of pediatric patients. Based on this study's findings, implementation of a brief provider-led screening tool into pediatric care practices may contribute to this gap.

Purpose Although spiritual/religious strengths (SRS) are widely believed to be a protective factor for youth physical and mental wellness, scant evidence is available regarding how much and in what direction a person’s past adverse experiences can affect the said protection. The study aims to validate the overall protective effect of SRS on health and investigate the mutual effect modification of SRS and accumulated adverse experiences exposure. Methods The study is a cross-sectional design utilizing the Child and Adolescent Needs and Strengths (CANS) administered to foster care youth aged between 5 and 17 in a large, mid-western state from July to December 2020. Logistic regressions were used on a gender-balanced working sample of 4,802 youths to model the odds of physical and mental unwellness measured by 12 behavioral and emotional needs (BEN) items in CANS and the combined multi-BENs (MBE) as 4 or more BEN items, given the presence of (a) SRS identified by CANS, (b) past trauma as having 4 or more out of 10 adverse childhood experiences (ACEs) items on the CANS, denoted as multi-ACEs (MAC), and (c) co-occurring SRS and MAC. Results Primarily, the study found supported the protective benefits of SRS as the presence was associated with lower levels of BEN. However, the higher levels of adverse experiences exposure were associated with an attenuation of the relationship between SRS and BEN. Secondarily, females were found to have higher SRS and lower BEN than males; adolescents between 13 and 17 had disproportionally more ACES, greater BEN and lower SRS; Black youth had disproportionally more trauma exposure and higher BEN, but had higher SRS. Conclusion The findings imply that having spiritual/religious strength helps promote wellbeing among foster care youth. However, it appears the greater levels of traumatic experiences exposure can overwhelm this positive impact. These findings are consistent with the complex literature on the role of spiritual/religious strength in mental health and may help clarify this complex relationship. Trauma-informed intervention should be considered nuanced approaches to address SRS among children and youth who present with these strengths.

INTRODUCTION:The increased threat of natural disasters makes understanding the relationship between community resources and children's mental health critical. Mental health care efficacy and access are crucial to assessing the quality of community mental health care availability.OBJECTIVES:The primary objective of this scoping review is to investigate the relationship between children's mental health and community mental health resource efficacy and accessibility after a major disaster.METHODS:Conducted a systematic search to identify epidemiologic and health service utilization studies assessing the relationship between disasters and subsequent health service utilization amongst children and adolescents.RESULTS:The research returned 1682 potentially relevant studies and 31 articles were selected based on identified criteria from pre-selected databases.CONCLUSION:The studies conclude a gender and age-based disparity in access and efficiency of children's mental health services. The studies also identify the need for greater resource distribution and organizational structure.

Understanding and addressing the impact of adverse life events is an important priority in the design of helping systems. However, creating trauma-informed systems requires efforts to embed effective trauma-informed work in routine practice. This article discusses a model for developing trauma-informed systems using the Transformational Collaborative Outcomes Management (TCOM) framework, a strategy for engineering person-centered care. Person-centered care is naturally congruent with trauma-informed care. We describe the initial stages of implementation of a trauma-informed standardized assessment process to support the sustained evolution of trauma-informed care. Distinguishing between traumatic experiences and traumatic stress is fundamental to an effective trauma-informed system. We describe two sets of analyses—one in a statewide child welfare system and the other in a statewide behavioral health system. These projects found opportunities in the analysis of the detection of traumatic stress based on traumatic experiences to inform practice and policy. Being trauma-informed in child welfare is distinct from being trauma-informed in behavioral health. In child welfare, it appears that a number of children are resilient in the face of traumatic experiences and do not require trauma treatment interventions. However, delayed and missed traumatic stress responses are common. In behavioral health, misses often occur among adolescents, particularly boys, who engage in acting out behavior. Opportunities for the ongoing development of trauma-informed systems using the TCOM framework are discussed.

OBJECTIVE:The authors quantified the impact of the use of telehealth services on patient-level clinical outcomes among children with complex behavioral and emotional needs in Idaho during the COVID-19 pandemic by comparing data collected in 2020 with data for the same months in 2019.METHODS:Longitudinal statewide data of Child and Adolescent Needs and Strengths (CANS) assessments were extracted from Idaho's mental and behavioral health system. Prepandemic assessments were matched to midpandemic assessments. A linear mixed-effect model was used to explore four child-level outcomes: psychosocial strengths-building rate, rate of need resolution within a life-functioning domain, rate of need resolution within a behavior-emotional domain, and rate of need resolution within a high-risk behaviors domain.RESULTS:The number of new patients admitted to Idaho's state-funded mental and behavioral health program decreased almost twofold from April-December 2019 to April-December 2020 (N=4,458 vs. 2,794). For most children with complex needs, the use of telehealth was as effective in terms of strengths building and needs resolution as in-person services; for children whose caregivers had issues with access to transportation, availability of telehealth services improved outcomes for the children.CONCLUSIONS:The COVID-19 pandemic in 2020 was associated with a dramatic drop in the number of children served by Idaho's mental health program. Telehealth may effectively bridge mental health service delivery while patients and providers work toward the resolution of transportation issues or may serve as a more acceptable permanent format of service delivery for some populations.

Abstract Background: Children less than five years of age comprise the largest entry into foster care in the United State at approximately 30% in 2020. Very young children can respond differently to the same adverse life events. Detection of complex interpersonal traumas are core to providing appropriate interventions and prevention of reoccurring negative outcomes in these youth. Methods: Children with complex interpersonal trauma and who did not have traumatic stress symptoms were identified using Child and Adolescent Needs and Strengths data in a large midwestern state from 2010 to 2021. A logistic model was fit to determine effect of cumulative traumatic exposures (e.g. adverse childhood experiences) with increased events resulting in increased likelihood of symptomatic detection. We conducted a latent class analysis to understand the relationship between traumatic experiences, asset-based factors, and the detection of traumatic stress in children aged five years and under who had exposure to traumatic events but did not have detectable traumatic stress symptoms. Results: We detected three classes of youth described as resilient, missed, and unfolding. Very young children do demonstrate asset-based resilience when faced with traumatic experiences. A subset of children with missed diagnoses exhibit behavioral and mental health types similar to those with detected traumatic stress symptoms. Recognition of resilience in very young children is critical for designing systems that customize approaches of trauma-informed care. Conclusions: Detection of traumatic stress may be more difficult in young children. It is important to assess both traumatic stress and strengths to ensure that children who are resilient after exposure to traumatic experiences (i.e., do not demonstrate traumatic stress symptoms) are not referred to unnecessary interventions. Additional educational approaches are needed to help caseworkers identify symptoms of traumatic stress that mirror symptoms of other behavioral and emotional challenges. Precision medicine approaches are required to best match the interventions to specific needs of young children.

BACKGROUND:Children less than five years of age comprised approximately 30% in 2020 of foster care entries in the United States, and they are consistently the largest foster care entry group. Very young children can respond differently to the same adverse life events. Detection of complex interpersonal traumas is core to providing appropriate interventions and prevention of reoccurring negative outcomes in these children.METHODS:Children who (1) were identified as having experienced complex interpersonal trauma, but (2) who did not have traumatic stress symptoms were identified using Child and Adolescent Needs and Strengths data in a large midwestern state from 2010 to 2021. A logistic model was fit to determine the effect of cumulative traumatic exposures (e.g., adverse childhood experiences such that increased events were hypothesized to predict an increased likelihood of symptomatic detection. We conducted a latent class analysis to understand the relationship between traumatic experiences, asset-based factors, and the detection of traumatic stress in children aged five years and under who had exposure to traumatic events but did not have detectable traumatic stress symptoms.RESULTS:We detected three classes within this population of very young children, who were described as "resilient" (demonstrating asset-based resilience when faced with traumatic experiences), "missed" (those who exhibit behavioral and mental health types like those with detected traumatic stress symptoms but who were not detected as such), and "unfolding". Very young children do demonstrate asset-based resilience when faced with traumatic experiences.CONCLUSIONS:Detection of traumatic stress may be more difficult in young children. It is important to assess both traumatic stress and strengths to ensure that children who are resilient after exposure to traumatic experiences (i.e., do not demonstrate traumatic stress symptoms) are not referred to unnecessary interventions. Additional educational approaches are needed to help caseworkers identify symptoms of traumatic stress that mirror symptoms of other behavioral and emotional challenges. Precision medicine approaches are required to best match the interventions to specific needs of young children. Recognition of resilience in very young children is critical for designing systems that customize approaches of trauma-informed care.

Objective To develop and test predictive models of admissions to a psychiatric residential treatment facility (PRTF) in transitional age youth using routinely collected health insurance claims and enrollment data.Data Sources We used outpatient service and pharmaceutical claims from Medicaid beneficiaries aged 6-to 21-years old in Kentucky for the years 2010-2017.Study Design We assessed over 1,250 predictors (derived from Medicaid claims data) prior to the first PRTF admission. An ensemble machine learning (ML) algorithm based on logistic regression models fitted to a random subsample of the original data was used to predict pathways to the first PRTF admission. Discrimination performance of the ML ensemble was evaluated by comparing predictions to actual outcomes and calculating area under the curve (AUC), accuracy, sensitivity, and specificity. Additionally, a multivariate logistic regression model was fit to investigate the contribution of the continuity of mental health care after the initial PRTF admission on the risk of readmission.Data Collection/Extraction Methods We identified N = 519,011 unique children and youth with at least one outpatient service or pharmaceutical claim during our study period (January 1, 2010 through December 31, 2017).Principal Findings Fewer than 0.5% of children and youth in Kentucky had an episode of PRTF admission. Despite a very low prevalence of PRTF admission, classification accuracy of the ML ensemble for identifying PRTF youth achieved over 90% accuracy (AUC = 0.96). Factors associated with the initial PRTF admission were having been prescribed anti-psychotic and anti-manic medications, and receiving outpatient psychiatric care. Within six months after the initial PRTF discharge, there was a surprising drop in service utilization with a large proportion of youth not appearing to receive any follow-up care.Conclusions Despite the fact that admission into a PRTF was a relatively rare event, our findings suggest that it is a predictable event among youth with identified mental health conditions who are receiving care in the community.What is known on this topic What this study adds ### Competing Interest StatementThe authors have declared no competing interest.### Funding StatementThis work was supported by the State University Partnership (SUP) research program of the Kentucky Cabinet for Health and Family Services (CHFS), and by the University of Kentucky.### Author DeclarationsI confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.YesThe details of the IRB/oversight body that provided approval or exemption for the research described are given below:The University of Kentucky institutional review board approved this study.I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.YesI understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).YesI have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable.YesAll data for this study is restricted.